January 18, 2012 Dr. Darria Edit Leave a comment

The other day I had a female patient that was truly miserable.

Not the tragic, immense loss-type of miserable.

No, this was the “I have four children under the age of 12 at home and they all have vomiting and diarrhea and today I started to have the same symptoms too” type of misery.  Recently, I have seen a LOT of this in the emergency department.  Gasteroenteritis (“technical” term for the stomach flu) often peaks in the winter and is also caused by episodic outbreaks.  New York City saw a 50% increase over the holidays. You may have even seen the news yesterday of a cruise ship that was forbidden from its scheduled docking at the Falkland Islands due to an onboard stomach flu outbreak.

While having an illness where your body seems to be assaulting you from both “ends” of your gastrointestinal system may be one of the most helpless and…well…gross… conditions, there are a few things that you can do to minimize your misery during this time.  Wash your hands, don’t share food, start hydrating  AS SOON AS symptoms start in order to prevent dehydration, and if you keep vomiting, talk to your doctor about getting a prescription for anti-nausea/vomiting medications.   Read below for more details and suggestions!

How it’s transmitted:

The most common causes of gastroenteritis are viruses: rotavirus, adenovirus, and norovirus. Unfortunately, these are VERY hardy bugs—notoriously difficult to eradicate, and only 10-18 virus particles are needed for infection.  They can be transmitted on infected surfaces, as airborne droplets, in food, water, and hands.  The best prevention is through meticulous hand-washing with soap—decreasing the risk of infection by 50%.  Alcohol-based sanitizers are also a great resource.

Symptoms:   

• Onset of symptoms usually starts 24-48 hours after infection, usually abrupt.
• Most patients have vomiting and diarrhea (4-8 bouts of diarrhea per day), but some have only one of these
• Most patients also have generalized body aches, headache, and just feel plain awful
• 50% have a mild/moderate fever with a temperature of 101-102F
• In most patients, the illness runs its course after 2-3 days, with a full and rapid recovery

Treatment:   The primary therapy is to keep well-hydrated to allow one’s body time to heal itself.  Infants, elderly, and debilitated people are at higher risk of dehydration, so need close attention.

Once dehydration starts,  a vicious cycle begins: mild dehydration –> lethargy,  mild abdominal pain, and nausea so drink even less —> vomiting/diarrhea continues –> worsened dehydration –> drink even less fluids –>  ER visit for intravenous fluids (that possibly could have been prevented with early fluids)

(1) Oral rehydration: I advise all of my patients, especially parents of children, to start a rehydration fluid AS SOON AS they start to have symptoms of gastroenteritis to prevent the vicious cycle.

As long as you are able to keep down fluids, then this should be your #1 priority.   Some patients come worried because their children are not eating regular meals during this time—but that’s ok, as long as they are drinking adequate fluids.

Fluids that are made specifically for rehydration are the “Oral Rehydration Solutions”, which were first pioneered by the World Health Organization.  These include the official WHO ORS, but also more commercially available ones such as Pedialyte, Ceralyte, Enfalyte, and Rehydralyte.

•  Gatorade/Powerade are not equivalent to these fluids, (sports drink are made to replace fluid losses from sweat, not from gastroenteritis), but may be sufficient if you’re  not already dehydrated
• diluted fruit juice and saltine crackers or broth may also be adequate if you  are not severely ill

(2) Pepto bismol / Kaopectate / Maalox: These can help in decreasing the severity of abdominal cramping. However, they will not affect the severity/duration of the diarrhea.

(3) Acetaminophen (Tylenol brand): great for the various body aches and headache associated with this illness

(4) Prescription anti-nausea medications: If a patient cannot keep down fluids because of vomiting, but is not so sick that they need to be in the hospital, I often prescribe a short-course of anti-nausea/vomiting medicine.   I’ve had many a friend and patient go from curled up in a miserable ball to sitting up, alert, and drinking gingerale simply after alleviating their vomiting.  Once they can stop vomiting, they can keep down the necessary fluid, and it makes a WORLD of difference.  Speak to your doctor about getting a prescription for one of these medicine, which include Reglan, Zofran, and Compazine.

(5) Diet: Once you can keep down fluids and are sufficiently rehydrated, slowly start to add back food into your diet.

• Breastfed infants: The CDC advocates that once an infant has been rehydrated, they can be restarted on breast-feeding, which can actually reduce the volume and duration of symptoms.
• Older infants, children, and adults: avoid foods with high levels of fat and simple sugars, sticking to complex carbohydrates, lean meats, yogurts, fruits and vegetables if you are able to tolerate them.  If even those things make your stomach worse, stick to the “BRAT” diet (bananas, rice, applesauce, and toast), although it’s not absolutely necessary.

When to seek care from a physician:  I have found that most of the patients that come to the emergency department simply need medicine to prevent vomiting and hydration (either intravenous or by mouth). However, a small proportion of patients could develop more severe illness, so seek medical care if you see the following:

• signs of dehydration:
  • in children: very dry mouth and eyes, no urine/wet diapers for 4-6 hrs in babies/young children, or 6-8 hrs in older children, no tears when crying, sunken circles around eyes
  • in adults: significant dizziness, having a very dry tongue or mouth, significant muscle cramps, confusion, urine that is dark yellow, or not needing to urinate for several hours
• blood or mucus in stool
• fever >101.3F
• severe abdominal pain
• recent antibiotic use or hospitalization
• unable to keep down any fluid due to vomiting
• elderly, children less than one year, and patients with underlying severe illnesses or compromised immune systems are at higher risk of getting more sick, and should be evaluated sooner if they have any problem

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‘Tis the Season—for Colds and Coughs! Use this advice to bounce back quickly

I received a great emailed question the other day about the use of Zinc for colds, and while working in the ED this week, it seems that everyone has a cold and cough! So, this week’s topic will address the “common cold and cough”  (and see below for the answer on Zinc).  With adults averaging two to three cases of the “cold” per year and preschoolers five to seven, it’s no surprise that it’s that time of the year again.  Colds account for 40% of all time lost from jobs, so getting back on your feet as quickly as possible is a huge benefit.

Use this information below as your “Go-To Resource” for the upcoming cold and flu season.  I’ve also included at the end a couple of “cheat-sheets” for the most complicated cases, such as children, pregnant women, and adults with high blood pressure—so print it out and take it with you on your next trip to the drug store!

Treatment for the cold and flu focuses specifically on symptomatic treatment, since the vast majority of these are caused by viruses that your body will eventually conquer.  So, treatment focuses on minimizing how miserable you feel while you give your body the time to do this! Antibiotics are not effective for common cold symptoms, and are reserved for patients with bacterial conditions such as Streptococcal pharyngitis (“Strept Throat”), ear infections, pneumonia, and others.

• The symptoms usually last for up to 7-10 days in the average healthy patient.  They last 3-4 days longer in smokers.
• Pain/Fever treatment:
  • Acetaminophen (Tylenol) 650mg every 4-6 hrs for pain or fever.  Do not exceed 4grams in 24hrs
  • Ibuprofen (Motrin or Advil) 600-800mg every 8-12 hrs for pain or fever
• Nasal Pressure/Congestion: Topical therapies:
  • Saline sprays – spray ample amount into nostrils, then blow out until you are able to clear congestion
  • Neti pot—accomplishes same as saline sprays, more effective (people swear by it), but some people find it uncomfortable
  • Afrin: great for constricting the vessels in the nostrils and decreasing swelling and congestion.  Do not use for more than 72 hours, as using it longer can cause rebound nasal congestion
  • Nasal steroid sprays: [*Rx] good for people who have allergic rhinitis, or runny nose and congestion due to allergies
• Nasal Pressure/Congestion: Decongestants:
  • Pseudoephedrine (Sudafed, in many other cold therapies) – temporarily dries/clears nasal passages.  Pseudoephedrine is now sold only “behind-the-counter” and requiring ID, but it does not require a prescription
  • Phenylephrine: this has largely replaced pseudoephedrine in many medications, but research has shown that it is LESS effective than pseudoephedrine at treating congestion symptoms
  • Patients with Heart Disease or High Blood Pressure: these medications can increase blood pressure and heart rate, and may cause anxiety or insomnia. Be cautious if you are sensitive to these medications and do not take before bed.
  • Others: Ephedrine, Naphazoline, Oxymetazoline)
• Cough Suppressant(Anti-tussives): helpful if you have a cough that is so severe that it interferes with speaking, breathing, keeps you awake at night
  • Dextromethorphan (Delsym): affects the “cough trigger” in the brain
  • Codeine: Codeine can be added to expectorants (see below), so you get both expectorant and cough suppressant benefits.  This addition WILL make you sleepy, however, and you should avoid driving/operating machinery for at least 6-10 hours after taking it.
• Expectorant: thin the mucus in the air passages to facilitate coughing up the mucus and clearing airways
  • Guaifenesin (Robitussin Chest Congestion, Mucinex, Diabetic Tussin, Vicks Dayquil Mucus Control)
  • Guaifenesin with Codeine (Robitussin with Codeine) [*Rx]  – especially good if your coughing is keeping you awake at night
• Anti-histamines (useful if your symptoms are more due to allergies, or sneezing, itching/rash, watery eyes and runny nose)
  • Make you sleepy (1^stgeneration antihistamine)
    • Diphenyhydramine (Benadryl)—will make you sleepy but the most effective
    • Chlorpheniramine
    • Don’t make you sleepy (2^ndgeneration)
      • Loratidine (Claritin)
      • Cetirizine (Zyrtec)
    • Pepcid: the anti-histamines listed above block the 1^st type of histamine receptor (H1).  Pepcid and other antacid medications block the 2^nd type (H2 receptor), but there is some cross-reactivity, and some patient s find that taking both an H1 blocker and a H2 blocker can increase their symptom improvement
• Vitamins and Herbal Remedies:
  • Zinc: This therapy has been around since the 1970s, with conflicting evidence.  A recent research paper found that if Zinc is taken within 24hrs of onset of cold symptoms, it significantly reduced the duration and severity of symptoms. Adverse effects of zinc include vomiting (so ALWAYS take these supplements with food!) as well as a bad taste.  The FDA has put a warning against the intra-nasal forms as they can cause disruption of the sense of smell, so stick to the oral versions.
    • Since Zinc can irritate the stomach, if you find that you are particularly sensitive, take it not only with food but also with an antacid such as Pepcid or Zantac
    • Vitamin C: Once cold symptoms have started, Vitamin C has not been shown to be better than placebo for treating symptoms
    • Echinacea: no data supports its efficacy in treating the cold
• Other treatments:
  • Humidifier: a 2004 study of 319 patients showed that inhaling warm vapor reduced symptoms by 31% and decreased nasal congestion
  • Short course of steroids[*Rx]  if there is a component of reactive airway disease (or asthma) to your disease
  • Short course of albuterol inhaler  [*Rx] (for the same reasons as the steroids)
• Prevention:
  • • Vitamin C: While Vitamin C seems to not be helpful once the symptoms have begun, some studies have shown that it MAY  be useful for preventing the cold in the first place.  Once 5-year study inJapanshowed that 500mg daily of Vitamin C significantly reduced the frequency of colds, although it had no effect once the cold symptoms had begun.